greene and. knox and, you know, the whole gang is there. they're all crying. and then he gets in a barge and and sails off to his going to annapolis to surrender his commission in the army. and then he's going back to mount vernon. the war is over for him. so in some fashion, i will end it there. the latest book about the middle years of the revolution is the fate of the day. the author is rick atkinson. thanks for letting us wander good morning, everyone. i'm robert door, the president of the american enterprise institute. and i'm very happy to welcome you today to this discussion of my friend tom friedan's great new book, the formula for better health how to save millions of

lives, including your own. tom is going to speak for a while, and then we're going to engage in a conversation, and then we'll open up to questions from the audience. just a little background on tom. he is the he was the director of the center on disease control and cdc under the during the obama administration. and he is currently the ceo of resolve to save lives. but what he is among other things, is a hero in the public health world because he has saved lives during his career. he's also an old friend. he and i served together in the bloomberg administration. the mayor administration of michael bloomberg in new york city. i was the commissioner of social services. he was the commissioner of health. and he was the kind of leader of a public agency who was willing to set very high goals and take responsible for achieving those goals. even goals that might be viewed from the perspective of caution as city administrator might be

outside his complete control. so to give you an example and the the the educators might set the goal of of improving educational outcomes for children. good goal. poverty fighters might set the goal of reducing child poverty. good goal. crime fighters might set the goal of reducing crime. good goal. tom said the goal of making new yorkers healthier to live longer, better, more flourishing lives. and i can remember when i first became commissioner, he was already there and in his way he the word came over. he wanted to see me. and i said, i better go see. because tom was a superstar in the administration. and we went over to have lunch and he had a little he had a little card in his in his upper left pocket. and it was it was his list of things for me to do. and it was very direct and strong. and what he said to me was there

is one health indicator here in new york city that right now is going in the wrong direction. it's the only one, but it's going in the wrong direction. and that's childhood obesity and obesity and you and i need to do something about that. and then we set about various efforts to make that make progress. there, which we'll talk about later. but again, he was willing to embrace a ambitious goal that wasn't entirely within his control and then take responsibility for achieving it. and i admire that greatly. he's now come out with a new book. there's a lot going on in public health. if you ever noticed. we're going to cover all of it in the question and answer discussion. but for now, i want to start out with letting tom carmen present a little bit about the book and then we'll have a conversation. tom. thanks so much. robert it is great to be here. thank you very much for hosting this. i'm looking forward to the

conversation. robert has always been one of my favorite people, but really focused, really dedicated, really thoughtful. and we need more discussions like this, more discussions that look at different perspectives, that embrace different perspectives. this is important not just for the politics of our country, but for the health of our country. public health problems don't have to be partizan. public health choices are often political, but hopefully not partizan. everyone wants to live a longer and healthier life and there are proven ways to do that. there are different ways to approach it. but what i've tried to do in this book is draw together decades of experience, not just in new york city and the us, but globally, not just my own experience, but public health generally to identify and approach a formula that has actually already saved millions or to be actually more

quantitative, hundreds of millions of lives. and it can be used to save millions more and it's also relevant for your personal health. and that approach is see, believe, create three steps. it starts with the really easy thing. see what's invisible. this started and i learned this in the research for the book, which has taken me ten years to write. in 1662, a cloth merchant named john grant did the first ever epiphany immunologic analysis of society. as far as i can tell, and i've given many talks now at public health schools, no one has corrected me. so i think it's correct. no one had previously done an epidemiologic analysis of communities. he analyzed what people died from. he looked at the economic

implications of disease. he saw that certain diseases killed a lot of people, but other diseases made so many more sick that you couldn't bring in the harvest. he saw emerging diseases like rickets, which increased from 1630, the 1660. he saw he asked the question, what's the most important indicator of how healthy a society is? he said the proportion of people who live to 70 in 16 60s london, it was only 7%. today in the us, at 70%. but in the healthiest societies around the world is 80%. and ideally it should be 100%. there's a lot that we don't see that's really important. we don't see microbes and toxins and trends that could kill us. we don't see whether programs that are perfectly well intentioned are failing or succeeding. we don't see the rigorously

proven pathway to progress. and by seeing each of those things, we can make a huge difference. but we also sometimes don't see why we don't take action on the things that we know are going to kill us. when i was cdc director, one of the most striking things i experienced was understanding the tobacco lab at the cdc. the cdc has a laboratory that analyzes cigarets. they purchased a machine. it's called a smoking machine that smokes cigarets and analyzed them. when they tried to purchase that machine, the tobacco industry tried to block the sale. but the company wanted to sell their products, so they sold it in the years that followed, the scientists at the tobacco lab realized why the tobacco industry had tried to block that sale. the first thing they realized is that when a smoking machine

holds a cigaret, it uses a clamp. when a person holds a cigaret, they use their fingers. the filters had many holes and and by covering those holes with your fingers, you get all of the smoke from the cigaret. when you put a clamp in, you get a lot of smoke. you get a lot of air from the environment, which dilutes the toxins and cigaret. so the smoke machine, systematic early under estimated the level of contaminations or toxins or poisons in tobacco. but that was just the first they realized as they analyzed more that the tobacco industry was making sure that there was more nicotine in the tip of the cigaret than the base. that way, after people had finished smoking half the cigaret, they stub it out because they need another hit of nicotine. but that was just the beginning. they realized that the tobacco industry was making the tobacco more alkaline, more basic by adding urea and other substances

because that increases the absorption of nicotine in the lungs. they were adding sugars which increase the binding of nicotine to receptors in the lungs. and flavors like menthol, not only make tobacco smoother, but they also appear to increase the number of nicotine receptors in the brain. and with all of these changes in a cigaret, you get more nicotine free nicotine or crack nicotine from a puff of a cigaret than you do from an injection of nicotine into your veins. smokers may think, oh, it's a failure of my personal willpower that i'm continuing to smoke, but that failure isn't only created by that individual, that failure is created by systematic changes in the product that the industry has made. and that's kind of a metaphor for a broader challenge that we don't recognize all of the

influences on our behavior, whether they're social norms or inaccurate perceptions of ourselves or the world. and that has big implications because we may inappropriately take credit for something that we don't deserve credit for or blame someone for, something that they really don't deserve. blame for. this is not to abdicate individual responsibility. this is to say that working for health is both an individual responsibility and a societal responsibility. and seeing the invisible means, seeing the forces that are causing us to be ill, disabled or to die young, and seeing the rigorously proven pathway to progress. now, once you can see the invisible next is really easy. you have to believe the impossible. so believing the impossible means recognizing that there's a lot of change out there and the current practice of our health is not immutable. it can change. it has changed.

and the first way to believe that we can make a lot of progress is to recognize that we already have the rate of heart attacks and strokes decreased by two thirds in the us from 1960 to 2010. if that hadn't happened, 20 million more americans would have died from heart attacks and strokes. smallpox used to kill millions of people every year. it's gone forever. there's been a lot of progress, i think, frankly, in public health and and generally in some groups, particularly on the left politically. there's a real reluctance to say things are better than they were because there's a sense that that saying things are okay now, but things can be better, but still bad, bad, but better. these are contradictory concepts that we need to keep in our minds. and by showing that there's been a lot of progress in areas, i think rather than giving us complacency that, oh, things are okay. that gives us more urgency, that

we can make them even better. now there are other ways to strengthen belief that we can shatter this illusion of inevitability. and one of them is to make systematic progress, to have phased, expand programs that can make a big difference. and we do that in the organization that that i run resolved to save lives. we work with more than 40 countries around the world. we partner with them for country owned, country led solutions to the world's deadliest problems. in fact, all proceeds from this book will go to support programs like that around the world. and what we find is when we began, for example, people just couldn't imagine that you could treat high blood pressure in primary care clinics in low income countries. it was complicated. it was expensive. we made it simple. and inexpensive. and now 40 million patients are on treatment in programs supported by these countries. so phased progress is very

important in building that belief. and finally, optimism. optim ism is supremely important. bill figgy is a wonderful doctor who led the global eradication of smallpox. and he was working in india doing lots of different things meetings, procurement, field supervision, hiring lots of stuff. and someone came to kind of assess his performance and ask him what is your job description? and he said resident kahneman, my job is to keep people believing we can do this. now, it wasn't a con with confidence. more than 200,000 health care workers and more than 70 countries found more than 10 million people who had had contact with a smallpox patient. gotham vaccinated and quarantined and eradicated smallpox from the world. saving literally hundreds of millions of lives.

now, belief is really important. seeing the invisible is really important, but the hardest part, the really hard part, is creating a healthier future. people figure was asked after the eradication of smallpox, what next? and he replied, the eradication of bad management. one of the real problems in implementing effective public health programs is that they have to work in government systems, and government systems are slow, inefficient, bureaucratic and often poorly prioritized. it's said that every time you make one thing a priority, you make a bunch of enemies and one in great. and so what can be done first is to organize well, to structure things well, to improve institutional capacity, to prioritize. the eisenhower matrix is really important.

most things that are urgent or not important, most things that are important or not urgent. but if you can find those things that are important and maybe not urgent and address them, you can have a virtuous cycle where you're addressing more things that are effective and less things that are the crises of the day. so creating a healthier future means organizing. well, it means simplifying because only simple approaches can be scaled. leonardo da vinci said. and steve jobs used this in his first shareholder report. simplicity is the ultimate sophistication. it also means communicating effectively, and communicating effectively means listening well to begin with. and identifying what people are hearing. what are the right messages? what are the right messengers? who are the right messengers? and how that can be scaled up and changed over time. and then overcoming barriers and

public health will always be the underdog. and that's because of a structural situation. one of the reasons we don't see one of the reasons we we don't take actions on the things that might kill us is a phenomenon known as the prevention paradox and the prevention paradox says that. the biggest changes in society, the biggest improvements and harms to health often don't come from the dramatic. incidents where you see something big happen. they come from very small changes that affect very large numbers of people. so take lead poisoning as an example or incidence of terrible lead poisoning are very dramatic and kill people cause long

lasting harm. and yet the harms from lead poisoning are much more invisible. it's low levels of exposure across entire populations. when robert and i were growing up, the average lead level of a kid in the us was 15. today, if a kid had a level of 15, we would urgently send out a team to figure out why. that's happening. and less than 1 in 3000 kids in the us has a level of 15 or higher. currently. the impact of that is massive in terms of fewer heart attacks, less kidney failure, better, better behavior. or better performance in schools. but it's invisible and that structural issue of the prevention paradox concentrated costs and diffuse benefits. that structure means that public health will always be the underdog. and in order to make progress, we have to figure out who are the winners and losers, who are the deciders and influencers,

who are the advocates and champions, and what are the partnerships that can make a difference? and what's a pragmatic way with the right timing to make progress on issues that will make the most difference for the most people? so public health has done great things. i think it can do great things in the future. but this will require looking systems radically at what works. understand what's really causing harm. believing we can make progress by making progress. and then systematically implementing a program to work together to create a healthier future. thanks so much. and. okay, i'm i'm running up because i have so many questions and i want to get right to them. i wanted to just say again, i'm robert shaw, the president of aei. this is tom frieden, the author of this great new book. this is also an event that we do with the help of our friends ed and helen hintz, who sponsor

these book events that we do. and i want to thank them. they're great supporters of ours. tom, one of the surprising things about this book to me, knowing you all these years, is that it's a lot about it was very helpful to me personally. i mean, there's a there's a sort of self-help aspect to this that, you know, there's a lot of literature in the bookstores where you go to get that. i didn't think i'd go necessarily get that from you. i was thought to be about the government and all that. and one of the surprises is that you focus a lot on a health risk or health factor that you think is something we should do a lot more about and that people don't recognize. and that is high blood pressure. and so tell us a little bit about why you think that's a much bigger risk factor and and problem for americans and and what we should do about it. you know, it's a it's a great way to think about the see believe create formula because until 1896, no one in the world

had ever even measure blood pressure. we just take it for granted. but it was an italian physician, silvio riva roshi, who used a bicycle inner tube and a mercury man ometer to figure out how to measure blood pressure. it was another how 50, 60 years before there was even the first medication to treat it. fdr died of malignant hypertension. his blood pressure was to 60 over 160, and he died from it. he was 63. it was not until really the 1980s that we recognize through superb studies done by a group out of oxford, england, that for every 20 point increase in blood pressure, starting at 115, the systolic over 75, the risk of a heart attack, stroke or death

from a heart attack or stroke at a young age doubles. okay. and it wasn't until about a decade ago when a terrific trial funded by the now called the sprint trial showed that if you bring blood pressure down not to 140, but to 120, you get about a 27% lower risk of heart attack, stroke or death. so lower is better, down to 115 or 120 in blood pressure. now, the the challenges are first, that. and let me just say, we we get our blood pressure measured every time we go to the doctor. we don't have any encounter with a health care profession at present. so are we not measuring it enough? what's the problem? well, it seems to me we know we you say that we see it. and i think we believe it. so what's the problem? why haven't why what? what what should we what should me and my doctor do differently? and then what should the government do differently? hypertension or high blood pressure is called the silent

killer. because the first symptom most people may have is a heart attack or stroke. and this concept that, oh, i can tell my pressure is up because i have headache. totally wrong. most high blood pressure has no symptoms at all. and that means health systems have to work well. and our health systems really don't work well. not in the us, not globally. so let's unpack that a little bit. so the first system is a heart. first symptom is a heart attack. but i presume the blood pressure has been rising. absolutely. so that's a symptom. but it has to be measured to see it at the sign. yeah. to be. to be to be. so are you going to say to me that people should see the doctor once a month? no. you know, when i was at cdc, i did a big effort called the million hearts program. we did this really good analysis that there were going to be 10 million heart attacks and strokes in the next five years. we could prevent 10% of them by doing a few things really well. we got the white house, hhs, 50

national organizations. well, we did everything right and we failed completely. okay, so it's so that this is not this is not inspiring, tom. well, we failed because we didn't see the invisible. we didn't see what are the real economic incentives underlying our health care system. and right now, if if you're a doctor and i'm your patient and you spend a lot of time and you get my blood pressure controlled, you're not going to make a cent more. and in fact, you're going to spend a lot of time that you don't have doing it. but if you fail to control my blood pressure and i have a heart attack or stroke, your health care system is going to make a lot of money. i don't think there's a single doctor in the country who intentionally leave their patient's blood pressure uncontrolled. but our system determines that happens. i can prove that that's the case because of kaiser permanente. kaiser permanente is different in kaiser permanente. the people paying for the health care and the people delivering the health care are the same. and the patients are going to be

their patients for decades. so kaiser realized in the 1980s, 90s ho we better control blood pressure because a lot of people are having heart attacks and strokes and their rate of blood pressure control is twice the rate of the us. so pay for results not not episodes. pay for health. pay. pay for help. pay for health. okay. and that's there's been some talk of that. but just going back to me and my doctor for a second, you do do a lot on diet and exercise and monitoring. i mean, isn't a fundamental message of this if your blood pressure is rising, tell your doctor we have to fix this. and then change your diet. yes. there are a few things that you can do. one is to switch the brand of salt. you use to a potassium enriched, low sodium salt if you don't have kidney failure. that's about as good as taking one blood pressure medication. you won't taste the difference, but your heart will know that there. change your salt. change your salt and use less, chef. and i would use to help physical

activity is the closest thing to a wonder drug. and to get the minimum dose of this wonder drug, it's 30 minutes, four days a week of a brisk walk. outdoor 30 minutes, four days a week minimum. all right. all right. so you acknowledge that there are things government can do with incentives on finances for health care system recipients of payments. and we've talked about that. and you also acknowledge that there's a lot of things the individual needs to do to change their behavior. but this is a risk for americans health that we're not paying enough attention to. absolutely. estimates are about 600,000 americans are killed by high blood pressure every year. and globally, it's the number one killer. it's really striking. we've just finished an analysis that globally, less than $1 out of every thousand dollars that goes into global health goes for high blood pressure. all right. dementia is another one that you talk about. what's going on there in public health in the united states? are we are we making progress on that? what should we do differently?

what's happening? it's interesting that the rates of dementia are decreasing. we thought they would increase, but they're decreasing. and one of the things i learned in the course of doing the research for this book is about half of all dementia is preventable with current available tools. the first is to control your blood pressure. in fact, there's a new study out that a target of 130 compared to a target of 140, that's the systolic pressure reduces your risk substantially. so that's a big finding that that's important. it is related to the higher blood pressure to the sixth main keys, the health. all are going to help with high blood pressure that dementia control. your cholesterol is very high blood pressure, control your cholesterol, physical activity, the getting enough sleep 7 to 9 hours a night, eating healthy and nutrition and avoiding toxins like tobacco and alcohol and pm 2.5. yeah. so there are other things on dementia that are interesting that are very much personal, like having a social network or speaking a second language or

playing a musical instrument. those have been pretty well proven to decrease your risk. now, tom, you mentioned diet and so i have to just ask you how you feel being the eat this, eat your spinach guy. you know, there's an old line that doctors use with patients like me. if it tastes good, spit it out. tom, what about joy? what about the joy of life? what about. come on. you know, robert in new york city, as you may know, a coffee with decaf and sweet and low is called a double. no fun. okay. i actually did not know that. and double. no double, no fun and all to often public health is seen as a double no fun. yes. yes. but we're not exactly. we're not. so first off, instead of denying yourself, great stuff that you love, why not find stuff you love that's healthy and have more of it? okay. so one of the things i also learned in doing this research

for this book is sweet potatoes. who knew that sweet potatoes are really healthy? right. and they're sweet and delicious. you know, you can make lots of ways. they're easy to make bananas. you're also very big on bananas. well, potassium generally. so people think of bananas, potassium. but but there's lots of things that are high in potassium and within reason, the things that are high in potassium, the more you eat the better. and that includes things like sweet potatoes and salmon. salmon, tomatoes and mushrooms. these aren't good food. right? all right. nuts, olive oil. these are healthy things. okay. you talk about the importance of recognizing progress. and then you you did a little diatribe on the tobacco industry here, which we greatly appreciated here today. and but the question on that one is there has been amazing progress in smoking. i mean, just just tell us that story because it is a remarkable thing. and americans seem to be happy

with this progress. shouldn't they be? yes. when i began my work as a disease detective, epidemic intelligence service officer, one of my fellow officers had done the study that showed that young children recognize the camel from camel cigarets more readily than they recognized mickey mouse or any cartoon character. and the rate of child smoking or teen smoking was 36%. more than one out of three teens smoked last year was 4%. okay. so there's huge progress there. most americans who have ever smoked have already quit. most people who still smoke want to quit. but smoking is still the leading preventable cause of death in the u.s. nearly half a million deaths a year. so we have more to do. how did that progress happen? it happened not because people got more willpower. it happened because government regulated. so you couldn't have cartoon

characters everywhere. government ought to be taxed very, very effective. yeah. money talks government, including in new york city. under mayor mike bloomberg, leadership made public places smoke free. because why should anyone have to come to work and risk getting cancer? because somebody else is smoking in their workplace. and changes like this made a huge difference. well, you know, i want to ask you about that one thing about smoking, because i agree with those changes. but why is it that the public health community is tolerating marijuana smoke and why aren't you on the bandwagon on that? i'm not. and i talk about it in the book. you're not on the bandwagon. no, i'm not. i think that decriminalization is one thing. legalization is quite another. and there is strong and growing evidence that widespread use of marijuana increases is mental illness, including severe and long term mental illness has some negative pulmonary results.

it's one thing to lock a lot of people up for something that is not causing a lot of harm. it's another to get another killer industry that's marketing things to people. you know, and let's just be clear about that. you're on the bandwagon of preventing the use of marijuana and reducing the use of marijuana as much as you can. decriminalize ation is one thing, but legalization, you don't agree with, i guess what i'm trying to say is i don't think we should have another industry encouraging people to use something that's harmful and we do right. and that's what legalization and it's been a disaster. i, i agree with you. and i don't think that the left honestly spends enough time on that. there are. i write about that. well, you know, there's there's there have been groups very strong talking about this. you probably didn't know benny primm, dr. benny primm created the addiction research training center in brooklyn, was a friend

of my father's. and the last time i saw him, he came to see me in atlanta. he was in a wheelchair on dialysis, still giving talks. yes. and he said the legalization of marijuana will be the death of our communities. okay. now let's talk about something it hasn't. also, another topic that maybe isn't going so well. and i want to see what your explanation for it is. you came to me all those years ago and child said childhood obesity is rising and it's the leading cause of type two diabetes, which is a killer. we got to do something about it. people have talked about it a lot, but really, obesity is still not better. why? i my my set of beliefs here is a little different than others. i think we don't actually know what's driving obesity. we have had a massive change in doubling, tripling of obesity rates in this country. and i can give you 5 or 6 competing explanations as microbiome ultra processed

foods, other things that that have some evidence for them. but i'm not sure whether one of them all of them none of them are correct. what i do know and what you and i worked on in new york city is that if you look at the data, you see the invisible goods surveillance system, something called the national health and nutrition examination survey, which just got cut by the way, leading off essentially potentially blind to what's actually happening with health in this country. so if you look at that physical activity hasn't changed that much in the time that obesity increased. so it's probably not that we're exercising a lot less calories increase it by about 300 per day per person, about half of that increase was sugary drinks. and this is an example of what happened where the the industry, the industry knows about this formula, see, believe, create because they tried to counter each aspect of it. they tried it. it's just normal to drink that much soda. no, it's like seven times more

than we drank a couple of generations ago. this is not normal amounts. these are highly concentrated sugars that people don't perceive. in the same way you eat a candy bar, it spoils your appetite. you drink coke. it doesn't. right? right. so. so you said you're not sure you know what's driving it, but you do think sugar sweetened beverages are there. and big part of the problem, part of the problem and and the effort to restrict the use of snap for sugar sweetened beverages is one cause that you and i have been united on over the years. yes. as and as is the trump administration. this is one thing i agree with and i think it's important that we preserve supplemental nutrition funding because hunger or paradoxically also increases obesity. so when people don't have enough to eat, they eat unhealthier foods and they're more likely to become obese. so done, right? like the program where there were important women infant children nutrition program,

important changes made the nutrition in which much healthier and improved child health. that kind of change in the supplemental nutrition program would be important as as you submitted the waiver request. we tried. we tried in the obama know was that it was the obama castration before you were there, i think. and then and then it sort of sat idle and and was rejected. and then the trump administration, the three secretary plus the cms administrator, all supporting it. and it's happening in states across the country. so we'll see what happens there. okay. we got more to work to do on obesity. you've got to we and i will say yes, globally, the one of the policies that's really promising is a black stop sign shaped warning on the front of the pack of unhealthy food that says too much salt, too much sugar, too many calories. yeah, this started in chile with one parliament. you elected official who pushed it year after year. it has spread to more than a dozen countries around the

world. and the emerging data coming out of that is incredibly strong. so that's a global health initiative. huge reductions in the us. i think it would probably be difficult to make that stand up in court currently, but that's the best practice. but we but i wanted to save this for last, so we'll get to that later. the secretary of hhs and his campaign against unhealthy foods and products. but before i get to that, i did want to one of the the the aspects of the book that i think is sort of understated, but part of what you've always stood for is a trust in institutions, including institutions of government, and especially public health institutions. and you're trying to reclaim that trust. you want to reclaim that trust. you want to get it back. and so do i. so do i think all americans. but covid had did some damage and the way we responded to covid, apparently has done some

damage. the polling data shows this. and i just wanted to ask you, the foremost public health expert, i know, what were the elements of the covid response that you think were the most damaging? was it the mask mandates? was it the excessive closures? was it overselling the vaccines, saying the vaccines could do more than they really could or didn't have some downsides? was it the lack of targeting, you know, during the response, it was kind of we're not going to say that this is particularly harmful to people over 65. and so we're going to target the closures and the actions at them or people who are obese. we're going to we didn't want to do that because for some reason, we had to treat everybody the same. that's one one. oh, what what was the biggest thing that, in your judgment and maybe there's something else that that caused this confidence in the public institution of public health to go down.

so i think all of the things that you list had nuanced but important errors made that were costly. but in my mind, the single biggest mistake made in both the trump and biden administrations on covid was poor communication. this was really fatal because of this, i think the public was whipsawed by different advice that came out, didn't see how the science was emerging. and i would say, in fairness to the cdc, they started exactly right. if you go back to nancy martin, who i know, she was the head of the respiratory branch, right. january, february into early march. and you go back and look at what she said. what is that, five and a half years ago? now, you could not change a word and make it better. she was right on target. she was saying we need to be humble. we don't know how bad this is going to be.

it could be really bad. but there are things that we can do. now, here's some things. here's what i said to my family over breakfast this morning. disruption to everyday life may be severe. we hope it won't be. it's not over yet. we're learning more. as we learn more, we'll share more with you all the right messages. but they were out of sync with what the administration wanted to say, that this is all going to go away and because of that, she was silenced. cdc was silenced for the remainder of 2020. and i think that was really important because you you you lost the thread. you lost the ability of public health and government to say, here's what we know, here's what we don't know. here's what's happening, here's what we're recommending and why. and i would i would go on that that this communication error was compounded in the biden administration. and when they insisted that the cdc and the white house be joined at the hip, well, what that meant was, if you didn't

vote for president biden, you weren't going to believe what was being said. cdc is in atlanta. there are, you know, pros and cons of that. but ideally, the cdc is medical or scientific advice insulated from politicians and we lost that during the pandemic. and we're losing it now. and that's bad for all of us. the one thing about community, people that say it was a communication problem is and i'm in the communication business, is that there are two elements to communication. the way you communicate and what you say. and i'm trying to figure out why i'm listening to you. what was the problem? was it the substance of the communication or was it the methodology of communication or was it there were different messages from different quarters? well, there's also communication. good communication starts with listening and understanding what people perceive, what they're hearing. making that visible and i think during covid, we had a consist

problem with inconsistent messaging. so if you have trusted messengers who are telling you, i'll give you an example, some of the things that the cdc and others are criticized for. i think are unfair because what happened was, as we learned more, we changed our recommendations. so when the first studies came out about the vaccines, they looked amazing, right? the first two months, people who got the vaccine didn't get covid. it looked like it was like measles vaccine where you get the vaccine, you don't get the virus. and then it became clear that that protective efficacy waned rapidly. so that the the covid vaccine protects you. but it doesn't protect you. failure was the failure, one of lack of humility. that was a big part of it. and say we're not sure. and that's what nancy messonnier at the cdc got so right over and over again that we have to be humble. okay. all right. now we've got two major changes happening in this whole world in

the new administration and the trump administration. we have a secretary of hhs. it's very determined on these issues. what is then aspect of what they're doing and maybe i should say it this way, what is an aspect of what's happening there that you like and what's an aspect that your biggest concern? i think the make america healthier approach is really important. it taps into valid and widespread concerns. what's in my food, what's in my water, who's making recommendations? who can i trust? those are really valid concerns. and when you when i when i read your book and you write about politics and the power of industry, there's a little bit of rfk jr that same rhetoric comes from him too. he's very anti industry in many cases. the reason that you and i couldn't get soda out of snap was because the industry. right? so did everything in its power to block that change. so kudos for for the progress

there. what really concerns me is that what they're saying and what they're doing are almost complete opposites that they say they want to address chronic disease and that wonderful program i describe to look at the tobacco industry that's been closed. tobacco is the leading cause of chronic disease in the us. they say they want to address environmental harms. they've rolled back protections against p fast and other environmental chemicals. that's a forever chemical. i might not be able to get the full name of it right, but per se. and that shows up in people's lives. in what way? oh, it can cause a range of health harms. we're still learning about these forever chemicals. they may cause cancer, they may cause dementia. other words, the effort to study that and monitor that so and to reduce contamination is contamination.

and that's something that is being that's been the responsibility of cdc or cdc. and epa. okay. and other parts of the federal government. so that's getting rolled back. they say they want to restore trust in institutions. but if you look at what they did, the advisory mittee on immunization practices, they really undermining trust. so for the first time ever, you have pediatricians, obstetricians saying we're not going to do what cdc recommends because it's not based on science, it's based on ideology. and you you you have they're saying, we want to restore gold standard science, but you really undermining that science. so what really concerns me is in the name of things that are good goals, they're actually undermining health. and again, if you look at the failure of million hearts, it was because we didn't see the economic drivers. i think you have to be frank about some of the economic drivers of some of this movement. they're selling stuff on the internet that hasn't been proven to do any good. they're making billions of dollars from that. they're using the highest of

vitamins and supplements. yes. that yeah, that's a part of this. that's a big part of this. and you're you're seeing also the trial lawyer industry saying, oh, we're going to make autism a compensable condition under the vaccine compensation program. now, we've studied it over and over again. there's no proven link between vaccines and autism. and millions of children studied no correlation. but if they can prove that, or even if they don't prove it, say it. it is so suddenly. there's a bank there for trial lawyers to get very rich. so i worry about what gets said versus what gets done. okay. we've covered a lot of ground and i want to make sure we've covered all the ground that you want to cover. is there some aspect of this book and of of the public health world that you want to make sure that you you raise here before we turn it over to questions from our audience? i think it's of the greatest

importance to recognize is that public health is about working together as communities, as a society, so that if you just go with the flow, you're not going to end up disabled or dying young. that public health is about the organized efforts of society to promote health. it's not about telling you what to do. it's about making it easier for you to do the things that will allow you to do what you want to do for longer. in other words, a strong public health system is essential for our individual health, for the productivity of our economy, for the productivity of companies in our economy, and for our national security and we are really at risk as individuals, as community, as as companies and as a country. to the extent that we undermine and don't support our public health programs. okay. i want to bring i'm going to

bring the covid experience back one more time, because that one of the stories that i tell or say about that experience is because you use the phrase the public health administrators are always the underdog. but there's one context in which they're not, and that is when you've got the commissioner of education and the commissioner of public security and the commissioner of transportation and the economic development people and safety net people and the public health person before the governor or the mayor, and they say all of the potential negative consequences of a really draconian shutting down of the economy, no school, no work, no money, no transportation, people shut in all kinds of consequences. and then the public health person says, yeah, but people will die, doesn't that sometimes lead to a controlling where the public health administrator isn't really the underdog? they're actually the winner in

the conversation. and didn't a little of that happen during covid that we allowed a fear of something we didn't know and understand and death to govern all of our decisions affecting millions of people, including schoolchildren. you know, one thing that is irreversible is death. yeah. okay. so it is important to avoid deaths. yeah, they can be avoided. okay. but i think without getting into all the nitty gritty, there were a lot of ways to minimize death with less economic and social disruption. i was strongly against the closure of schools. i was vilified by the cuomo administration for that position. i coordinated with arne duncan and margaret spellings to promote the reopening of schools in the fall of 2020 in a bypass design effort. we had studied this at in public health. we had seen that schools closures would have mass

negative consequences, but that wasn't followed. so you know, i think there's a lot of nuance in what was done when by whom. but it is the case that we it is important that people not die preventively. well, i agree with that, too. but i just think it's that sometimes we're governed by the worst, by a fear of the worst possible outcome for the smallest for a tiny population. and that can sometimes, i mean, overrun if you if you look at if you look at the work that the advisory committee on immunization practices used to do, yes, they were very rigorous about this. they would look at, oh, you know, if this kind of disruption happens, there will be these economic harms and that has health harms also. yeah. so add those in. yes. okay. all right. let's look for questions from the audience. i'm looking around here. there we go. right there in the front. we have your hand up and wait for the mic and we like questions as opposed to statements, but questions are good. thank you.

sure. thank you very much. interested in presentation. you've made it clear how you feel about using snap benefits for sugary sodas. more generally, how do you feel about restriction on the use of snap or how snap benefits are used. one of the one of the features of the recent waivers in the supplemental nutrition program snap, is that they're all over the map in terms of which foods are restricted and how ideally you would like for unhealthy foods to be unable to be bought with snap and ideally you would like for there to be some incentive for fruit and vegetables and healthier foods, which there is. there's a widespread longstanding program to promote small, though, is really no good. we had a pretty big in new york

where we made it as big as we possibly could. yes. so so i think that the concept is correct. it's one thing to to say to someone, you know, eat this, not that it's another to say we're using government money to provide food. why should we use government money to provide food that's going to make you sick? and then we need to use government money to take care of you. so i think similarly in food policy, one of the things that we did in new york city was a public food procurement program. and my organization resolved to save lives, works on this with countries around the world, which says quite simply, look what you eat in your own home is your business. but if you're going to sell something on government property, it needs to meet government standards for being healthy. this ends up being much easier to say than to do because there are all sorts of challenges to that. that means that you don't sell soda on government property, including parks. so there's lots of things that

are there. policy decisions where the role of public health, i think, is to say, hey, if we take this action, this is the likely outcome, but it's a policy decision. it's above our pay grade, quite frankly. our pay grade is to say, if this, then that this is what you can expect to happen from this action. okay. we have another question from anyone. yes, gabby, wait for the mic. gabby. so we hear a lot about microplastics these days. and i was wondering if you could apply the formula to what that looks like and also what kind of power we have as individuals, if the system is not yet flowing in the right direction to help us make those good decisions? and if we have even really good options, when a lot of what's available to us that we're exposed to outside of our control is full of things that are going to harm us. absolutely.

so there are known toxins in our environment tobacco, alcohol, soot or pm 2.5 that are killing lots of people. there are also there's also emerging evidence about microplastics now particles and endocrine disruptors easily three big and overlapping categories of chemicals that the cdc has shown are in in our bodies increasing and more and more scientific evidence links to harm. i think see to see the harms that these are causing, see the pathway to progress. that also means it's a large category. are some more harmful than others? there's a lot that we need to learn still about them. i believe we can make change. look what we did with led. you know, look what we did with pm 2.5. still too much, but we've made a lot of progress so we can make progress and then use a phased approach to reduce this and then create a healthier future that includes at every level so

government can regulate industry can innovate, we can simplify the messages because it's really complicated. what microplastics, how as individuals, yes, there are a few things that we can do. don't microwave stuff in plastic, don't store stuff. basic lead. try to cook without plastic and store without plastic. that means more stainless steel. you know, the the nonstick pans are great to cook with, but they may have some real problems, especially at higher temperatures and we don't yet know all of the harms and all of the harm that these things are causing. so, again, this is a matter of of, you know, what your risk tolerance, how much you want to do, what's difficult and for all of these things there are things that we can do differently. i will say one of the things that i have done differently since doing the research on the book, besides eating more sweet potatoes, is i do use a reverse osmosis contraption for my water

because 50% of the water in this country has forever chemicals like p fast in it, and it's hard to test for, but it's not so hard to get out. there are some challenges with that. there's some details you need. the alcohol needs to replace the magnesium and the calcium that you take out through the reverse osmosis. and there are different companies and some of the validate and some of them don't. it's kind of a wild west out there. but but there are some things that we can do individually that make sense. you've mentioned a couple of times the negative effect on our health of alcohol, and i study that carefully. and i was a little surprised at your chart because it says action and i want to read this average no more than one alcoholic drink per day for women. and two drinks per day for men. two drinks per day for men. and that seems a little too i mean, god, that could be. i mean, should i really that is that that limit is the max.

it's the max. no more. it's not. it's not a minimum. okay, i got that. but i guess i thought that was a little high. yeah, there's a debate about that. there's a debate about that. i go into this in some detail in the discussion of technical rigor, the data that suggests that there's a so-called j-shaped. i think person churchill was very happy to hear this and that would have been way too little for him. the idea that a little bit of alcohol is healthy is wrong. and and there is actually a linear relationship between the amount you drink and the harms. but what i'm saying is that doesn't mean prohibition, right? we tried that didn't work or actually long story, but one not possible to maintain that there's a risk benefit calculation. okay maybe it's an informal one. okay. but there's a risk benefit calculation. but but the plain truth is that there is no healthy level of